N.J. Admin. Code § 11:24B-2.10

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:24B-2.10 - Review of applications

(a) The Department shall determine whether an application is disapproved as incomplete within 30 days of the date of receipt of the application, and shall notify the ODS in writing of a determination of incompleteness, specifying the items that the ODS shall submit in order to make the application complete.

1. With respect to an application for certification or an application for certification modification, the ODS may resubmit the application with the required information, annotating it as a "Resubmission following Notice of Incompleteness" without submission of any additional application fee within no more than 120 days following notice of disapproval, and the review of the application shall remain active; however, the Department shall treat resubmission of an application at a later date as an entirely new submission, requiring submission of a new application fee, as appropriate to the type of application in question.

(b) The Department may disapprove an application at any time during the review process if the Department believes that the compensation arrangement between the ODS and the carrier involves the transfer of financial risk as defined at N.J.A.C. 11:22-4, and shall notify the ODS in writing accordingly, specifying the reasons therefor.

1. If, following a hearing in accordance with (d) below, it is determined, or an ODS otherwise proves to the Department's satisfaction, that the ODS is not accepting a transfer of financial risk, notwithstanding the passage of time involved, the Department shall reactivate review of the ODS' application without any additional application fee, except as may be necessary to reflect a change in the functions for which the ODS may desire to be certified.

(c) If the application is complete, and the compensation arrangement does not involve the transfer of risk, the Department shall approve the application, and provide notice of approval to the ODS in writing following a determination that the information provided by the ODS demonstrates that:

1. The persons responsible for conducting the ODS's affairs are competent, trustworthy and possess good reputations, and have appropriate experience, training and education to conduct the affairs of the ODS for the purposes for which the application has been submitted;

2. The persons responsible for the provision of health care services are properly qualified;

3. The ODS has the ability to assure that health care services are appropriately available and accessible for the carrier's covered persons;

4. The forms of provider agreements that may be used by the ODS with providers meet the standards set forth in this chapter;

5. The forms of the management agreements that may be used by the ODS with carriers meet the standards set forth in this chapter;

6. The ODS has the ability to meet all of the standards established by this chapter relevant to the performance of the functions for which the ODS is seeking certification; and

7. The ODS has the ability to meet all of the standards of 26:2S-1 et seq. relevant to the performance of the functions for which the ODS is seeking certification that are not otherwise specified in this chapter.

(d) When the Department disapproves an application for certification or certification modification for the reasons set forth at (b) above, or failure of the ODS to meet the standards at (c) above, the ODS may request a hearing within 30 days of receipt of the disapproval by submitting a request, in writing , setting forth with specificity the reasons that the ODS disputes the Department's notice of disapproval.

(e) When the Department disapproves an application for certification renewal, the disapproval shall be the same as a revocation of certification, and the provisions of 11:24B-1.4 shall apply, except that a disapproval made pursuant to (a) above shall not be treated as a revocation until such time as the expiration of the current certification occurs, as specified in writing by the Department.

N.J. Admin. Code § 11:24B-2.10

Amended by R.2009 d.243, effective 8/3/2009.
See: 40 N.J.R. 6529(a), 41 N.J.R. 2965(a).
Deleted (a)2, former (b) and (e), and (g); recodified former (c) and (d) as new (b) and (c), and former (f) and (h) as new (d) and (e); in (b)1, substituted "(d) below," for "(f) or (g) below" and the first occurrence of "the" for "The"; and in (d), inserted "or certification" and substituted "(b)" for "(c)" and "(c)" for "(d)".

Amended by 55 N.J.R. 1186(a), effective 6/5/2023